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itnTV “Conversations”: Radiology Trends with Bayer’s Dennis Durmis

At this year’s RSNAITN sat down with Dennis Durmis, Senior Vice President, Bayer Radiology to discuss Radiology trends. Discussion topics centered around three key areas where Bayer Radiology is responding to trends; including digitalization, workflow efficiencies and efforts to bring more focus to the Radiology patient experience. During the interview Dennis discussed Bayer’s digital strategy, features and benefits of their new injector, the MEDRAD®Stellant FLEX Injector and Bayer’s education efforts of the imaging needs of women with Dense Breast.

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At this year’s RSNAITN sat down with Dennis Durmis, Senior Vice President, Bayer Radiology to discuss Radiology trends. Discussion topics centered around three key areas where Bayer Radiology is responding to trends; including digitalization, workflow efficiencies and efforts to bring more focus to the Radiology patient experience. During the interview Dennis discussed Bayer’s digital strategy, features and benefits of their new injector, the MEDRAD®Stellant FLEX Injector and Bayer’s education efforts of the imaging needs of women with Dense Breast.

Interview with Geoffrey Rose, M.D., president of Sanger Heart and Vascular Institute with Atrium Health, in Charlotte, North Carolina, and a board member with the American Society of Echocardiography (ASE). He explains the impact if COVID-19 (SARS-CoV-2) on the cardiovascular service line and cardiac imaging. He said the virus has led to use of computed tomography (CT) not only as the frontline cardiovascular imaging modality to evaluate chest pain, but also for COVID-19 pneumonia imaging.

Rose said cardiac ultrasound is still used, but requires full personal protective equipment (PPE) and often abbreviated exams because of the close proximity of the sonographer and patient when performing echocardiograms. This has given rise to using dedicated point-of-care ultrasound (POCUS) systems to answer specific clinical questions quickly. Smart-phone based POCUS systems that use an app and a transducer plugged into the phone enable basic echo exams or evaluation of other parts of the anatomy quickly without the need to immediately sterilize an entire cart-based ultrasound system. These small systems also can be completely enclosed inside a transducer sheath and the phone and single transducer are much easier and faster to wipe down. He said the quality of the exams are not as good as fully enabled echocardiography systems, but it allows for quick assessments of ejection fractions and to triage if the patient needs more advanced imaging if the basic questions cannot be answered.

Since hospitals have shut down now for about two months, postponing normal checkups, and elective exams and procedures, Rose said doctors still need to visit with patients who have chronic conditions. Sanger and Atrium Heath modified its ambulatory electronic medical record (EMR) and is using video conferencing to perform virtual appointments now for the majority of these patients. He said telemedicine was not widely used before COVID-19 in his hospital system, but the pandemic will likely alter the care model for the future, with more telemedicine visits being used even after epidemic is over. He said use of POCUS and CT as frontline cardiac imaging modalities will also likely remain in place after the pandemic because of the efficiencies in care these technologies offer.

Right now, Bloom said it is difficult to test everybody and there is a shortage of masks, gowns and other personal protective equipment (PPE), and the imaging equipment needs to be sanitized each time it is used. He said it is just is not possible to image all the patients who need imaging right now. Hospitals also are trying to limit the number of healthy people people coming into hospitals for routine visits and tests to reduce their potential exposure to the novel coronavirus (COVID-19, SARS-CoV-2) and help containment efforts.

"The tests should be done, very simply, if it changes the care of the patient. If it doesn't change the care of the patient, and it can be postponed, it should be postponed," Bloom explained. "I would say 80 percent of our cardiac imaging exams have stopped. It has been very dramatic."

United Imaging began working on new solutions for the U.S. after getting requests from its customers and seeing the needs in China and Europe. The company is collaborating with different vendors, including Sea Box and AMST to build both semi-truck trailer CT scanning rooms and those built into customized shipping containers. Other vendors are helping with infection control, ventilation, and easier cleaning/disinfection to help protect healthcare workers and patients.

The first transportable CT scanner was installed at the request of Maimonides Medical Center, the largest hospital in Brooklyn, New York, on the front lines of the current crisis. As the hospital scales its operations to meet the needs of an expected influx of coronavirus patients, doubling its capacity to 1,400 beds, United Imaging’s scanner will help expand its capacity for imaging studies to support diagnosis and treatment.

Skali elaborates on the following points in his discussion, which are specific recommendations in the ASNC and SNMMI COVID-19 guidance document:
• Rescheduling non-urgent visits
• Rescheduling elective surgeries and procedures
• Using separate spaces for patients with known or suspected COVID-19 to prevent spread
• Ensuring supplies are available
• Promoting use of telehealth
• Screen staff, patients and visitors before they enter the department
• Minimize non-essential visitors into the department
• Record symptoms at the start of the shift
• Use personal protective equipment (PPE)for healthcare personnel
• If available, use PPE for patients due to concern of asymptomatic transmission of COVID-19
• Maintain strict hand hygiene
• Maintain 6 feet distance in all patient/staff interactions when possible
• Work remotely whenever feasible, especially with ready studies
• Rotating staff schedules for on-site and off-site work
• Use of rest only studies if possible
• Use of half-time SPECT to speed exam times
• Use of PET if available to speed exam times

Druz spoke on the unprecedented expansion of telemedicine in the U.S. under COVID-19, seeing more use in the last two months, as opposed to the past two decades. The Centers for Medicare and Medicaid Services (CMS) previously only reimbursed for Telehealth in rural areas it determined had a shortage of doctors. However, in early March 2020, CMS dropped the geographic requirements and allowed Telehealth usage across th country as a way to mitigate person-to-person contact and keep vulnerable, older patients at home for routine check ups with doctors.

Druz has subspecialty certifications in nuclear cardiology, adult echocardiography and cardiac computed tomography (CT) and explains how Telehealth can be used to pre-screen patients and get patient sign off on procedures prior to coming in for an exam, helping speed the process in the hospital and limit personal contact.

Concerns about the rpaid spread of COVID-19 also has driven many radiology departments to convert to wider use of teleradiology to allow more radiologists to work from home and reduce person-to-person contact within the hospitals.

The rapid spread of coronavirus has increased the value telemedicine solutions to help prevent person-to-person contact and take some clinicians out of the hospitals to work at home or office locations. This includes the use of teleradiology tools to read images and communicate with referring physicians.

Telemedicine allows for the continuity of care within healthcare facilities and patients and allows for safe distance without sacrificing the quality of care. It also saves patients from spreading germs to others, like while on public transportation or in the doctor’s waiting room, and to the healthcare providers who tend to them. Televisits also only last an average of 10 minutes, allowing physicians to assess patients more quickly and easily.

Jilan Liu, M.D., MHA, CEO for the HIMSS Greater China, explains how health information technology (HIT) was leveraged in China to help fight the outbreak of novel coronavirus (COVID-19, SARS-CoV-2). Her discussion includes use of artificial intelligence, telemedicine to reduce contact between people, using the electronic medical record to help record and track people COVID-19 patients had contact with, apps, internet hospitals, and how 5G networks helped speed up IT systems.

She was previously principal and consulting director of the Greater China Joint Commission International (JCI). As chief executive for HIMSS Greater China, Liu and her team made a significant breakthroughs with hospitals and the HIT industry in the greater China region to embrace international HIT standards, certification requirements and to rethink prudent approaches to IT investments and operations.

Interview with Mike Stone, M.D., an emergency physician at Northwest Acute Care Specialists in Portland, Ore., director of point of care ultrasound education at Butterfly Network Inc., and and former chief of the division of emergency ultrasound at Brigham and Women's Hospital, Boston. He explains what clinicians look for in lung ultrasound to evaluate patients for plural wall thickening and areas of congestion inside the lung typical of pneumonia and seen in patients with novel coronavirus (COVID-19, also referred to clinically as SARS-COV-2).

Small hand-held ultrasound systems may offer advantages over X-ray or computed tomography (CT), because the entire system can be contained inside a protective sheath, making it easier to disinfect the device rather than an entire imaging room. Point of care ultrasound (POCUS) systems also allow triage of patients in tents or other areas outside of the hospital where other imaging modalities are not available.

Stone shares examples of COVID-19 ultrasound images from Butterfly Network POCUS system technology, which turns an iPhone into an FDA-cleared ultrasound device for multiple POCUS exam types. It is the first POCUS system reported to be used for triage and monitoring COVID-19 patients.

At RSNA19, Philips discussed with ITN Contributing Editor Greg Freiherr how its IntelliSpace Enterprise Edition fits into the Philips portfolio, and how the corporate acquisition of Carestream Health IT might affect the company. The video also discusses how Philips will help prospective customers acquire its products.

EIZO medical monitors were showcased recently at RSNA 2019. Learn how the EIZO approach streamlines the effectiveness of your readings. From the NEW 30.9 inch, super-high-resolution, 12 megapixel multi-modality Radiforce RX1270, to the EIZO built-in features such as Point-and-Focus, EIZO holds to the ideal to harmoniously combine performance, ease-of-use and comfort. Learn the Shape of Comfort with EIZO. Stop by and visit with us at HIMSS, booth #4087.

At RSNA19, GE Healthcare introduced its Edison Open AI Orchestrator. The software has been designed to operate smart algorithms that might save radiologists time. ITN Contributing Editor Greg Freiherr discusses its benefits with Karley Yoder, vice president and general manager of artificial intelligence for GE.

ProFound AI is an FDA-cleared artificial intelligence (AI) system for reading 3-D breast tomosynthesis images. At RSNA19, ITN Contributing Editor Greg Freiherr spoke with iCad Chairman and CEO Michael Klein about the system, which has been clinically proven in a large reader study to produce an 8% average improvement in sensitivity, 7.2% average reduction in recall rate and 52.7% reduction in average radiologist reading time.

In this video, Izawa announces the latest imaging advancements available for the Aspire Cristalle digital mammography system with digital breast tomosynthesis, including S-View, a synthesized 2-D image reconstructed from DBT and other patient enhancements such as the comfort paddle to provide a noticeably more comfortable exam for the patient.

She explained computed tomography is the front line imaging modality, followed by MRI for more detailed examination of the soft tissue details. MRI tissue elastography can also help to differentiate pancreatitis from pancreatic cancer. Hecht also said PET-CT and endoscopic ultrasound also play roles in pancreatic imaging. She said new software is helping automate measurements and artificial intelligence (AI) is in development to help improve pancreatic imaging and to find new radiomic markers that might be missed by the human eye to better detect disease or risk stratify patients.

She specializes in cardiac and pulmonary imaging, and has particular expertise in using CT and MRI techniques in cardiovascular imaging and the differences of presentation in imaging between male and female cardiac patients. Ordovas is helping advance education around heart disease in women and bring great awareness of quality tools to diagnose heart disease and how heart MRI can help. She also is heavily involved in the use of heart MRIs for pregnant women, since there is no radiation, and patients with congenital heart disease where detailed imaging of the complex anatomy is required.

The use of cardiac MRI in congenital heart disease is common in serial imaging of patients with Tetralogy of Fallot (TOF), one of the most common congenital heart diseases for which patients are referred for post-operative magnetic resonance (MR) imaging evaluation. In the past few decades, surgery has proved successful, but most patients require repeat imaging throughout their lives and MRI can offer more detailed soft tissue imaging without the use of radiation.

An experienced technologist and two Agfa executives talk about what distinguishes the new Agfa 100s. Three key highlights include the quality of images that users can get out of the system for the certainty of the diagnostic; more flexibility that has been designed around the user; and its revolutionary platform.

The Arietta 850SE provides facilities with numerous features and functionality to get the most out of a system. The CMUT probe performs the role of multiple probes while the single-crystal C252 probe gets increased penetration. eFocusing simplifies scanning techniques and shearwave elastography provides unique feedback on tissue stiffness.

Hitachi announced the FDA clearance of its newest CT – Scenaria View – at RSNA2019. The View offers an 80 cm wide bore, 550 lb table capacity and powerful 84 kW generator as well as a 200 mm lateral shifting table. Installs in Georgia, Ohio and Florida are underway with more to come in the new year.

Ajay Choudhri, M.D., chairman of radiology, Capital Health, Hopewell, N.J., explains his center's experience using an artificial intelligence (AI) application to help auto detect intracranial hemorrhage. There are several AI stroke auto detection apps now available with FDA clearance or in development that were shown at the Radiological Society Of North America (RSNA) 2019 meeting. These are being adopted by hospitals and multi-center radiology practices the U.S. to flag suspected cases of ischemic stroke or brain bleeds for immediate reads.

The software also offers a second set of eyes for more difficult to detect cases. Quickly determining is a stroke is ischemic or hemorrhagic is critical to the path of treatment. If caught early enough, TPA can be injected into patients to clear clots causing an ischemic stroke, but can cause massive brain damage or death if injected into a patient with a brain bleed. At advanced neuro-interventional centers, quickly determining the type of stroke is needed to know if they need to revascularize a patient or manage a hemorrhage.

In this Conversations video at AHRA, Ryan K. Lee, M.D., describes the harm extravasation can do and why using power injectors to administer saline beforehand increases patient safety based on his experiences at the Einstein Healthcare Network.

This is a demo of the EOS orthopedic X-ray imaging system at the recent 2019 Radiological Society of North America (RSNA) meeting. The system allows for weight bearing exams. EOS Imaging System the first technology capable of providing full-body, 2-D and 3-D images of pediatric patients in a standing position at a low dose of radiation. The vendor said the scans are much lower dose than computed tomography (CT).

EOS captures bi-planar images with two perpendicular X-ray beams that travel vertically while scanning the patient from head to toe. In less than 20 seconds, the EOS exam produces simultaneous frontal and lateral, low dose images. The two resulting digital images are processed by EOS' proprietary sterEOS software to generate a 3-D model of the patient's spine and/or lower limbs. These detailed images with only 20 seconds of radiation were previously unachievable before EOS technology.

This is a hologram of a fracture from a computed tomography (CT) scan displayed by the start up company Voxon at the 2019 Radiological Society Of North America (RSNA) meeting. The technology uses a half millimeter thick glass plate that pulses up and down very rapidly while projecting 4,000 images per second. It can display standard DICOM radiology files or STL files used for 3-D printing.

There were at least four vendors showing holographic screens to display advanced visualization 3-D renderings of anatomy from medical imaging. All four of these screens could be viewed in true 3-D using normal vision without the need for special glasses or a virtual reality visor.

The images in this example flickers because of the different frame rates of the system and the iPhone used to film it, but the actual images appears much more stable.

Gillian Newstead, M.D., director of global breast imaging and former professor at the University of Chicago, explains a large breast MRI screening study presented at the 2019 Radiological Society of North America (RSNA) meeting.

The DENSE Trial Study Group included 40,000 women from the Netherlands who underwent standard mammography. Of these, 8,061 women were identified as having dense breasts and were offered supplemental MRI screening, and about half took advantage of the additional screening. Dense breast tissue which can obscure cancer on conventional mammograms but not on MRI. The MRI cancer-detection rate among the women who actually underwent MRI screening was 16.5 per 1,000 screenings.

He stressed the importance of CT protocol management to an imaging practice and showed examples of tools that can be used to develop consistent protocols across multiple systems. Little said it is important to develop awareness of the Management of Acquisition Profiles (MAP) IHE profile and features that should be requested from CT scanner vendors.

CT protocols, which include all clinical and technical parameters for a given study, are the starting point for achieving high-quality images with reasonable radiation and contrast doses. An imaging practice that desires to follow the "as low as reasonably achievable” (ALARA) principle and produce high-quality images should have standardized protocols across their enterprise. Accreditation standards require a periodic review of all scanner protocols. However, variations among vendors, models, and clinical indications mean that managing and optimizing dozens of parameters for each protocol on every scanner in a health system is challenging. Even when variations between systems are limited, managing protocol names and parameters across multiple systems can be difficult. The purpose of this symposium is to identify tools and techniques that may be used to manage protocols across multiple systems and to provide a framework for protocol optimization.

Heart MRI offers advantages over computed tomography (CT) and echocardiography because of its excellent soft tissue delineation and its ability to offer information beyond anatomical imaging, such as perfusion, morphology and metabolism. MRI can be technically challenging and the exams requiring a long time, but recent advances have helped cur cardiac imaging times down significantly. Automation and artificial intelligence (AI) also is making post-processing and quantification mush faster, brining it closer to the time it takes to scan and post-process CT imaging.

Northwestern is was one of the early adopters of cardiovascular MRI. Carr said heart MRI was not common in regular clinical use until the past decade at some luminary centers. In 2005, Carr was given the opportunity to develop a clinical cardiac MRI program at Northwestern.

He said MRI scanners have improved, and now much faster than a decade ago. They are also more optimized for cardiac imaging. While heart MRI is well known in large hospital centers, Carr said it still needs to develop and expand to community hospitals and rural hospitals outside major population centers.

Artificial intelligence is playing a significant role in cardiac MRI automation of speeding workflow and quantification. Carr said these technologies will become mainstream in the next few years. AI also will play an increasing role in risk prediction based on new image analysis algorithms in development.

The new NCRP 184 report covers the period between 2006 and 2016, the period of the most current CMS data. It shows a decrease of about 20 percent in the radiation dose the U.S. population receives from medical imaging, compared to the NCRP 160 that covered the period of up to 2006.

• Drop of more than 50 percent for nuclear imaging scans, mainly due to fewer procedures being performed;

• A 15-20 percent decrease across X-ray imaging modalities.

Mahesh says this shows the impact of using "as low as reasonably achievable" (ALARA) principals, new dose guidelines outlined jointly by numerous medical societies, and dose reduction initiatives like Image Wisely, Image Gently, and the American College of Radiology (ACR) Dose Index Registry.

He said there was growing concern a decade ago when the last council report was published, which showed a steep increase in radiation dose. This was mainly due to a rapid increase in the use of computed tomography (CT) and other types of X-ray based and nuclear radiotracer medical imaging. This prompted the ACR to create the Image Wisely program and push for the use of more thoughtful imaging doses based on patient size, using the "as low as reasonably achievable” (ALARA) principle. While CT dose was lowered, he said the biggest decline over all was in nuclear imaging.

This is an example of an augmented reality (AR) training system for transesophageal echo (TEE) created by the simulation company CAE. Rather than just looking at an overhead screen, this system allows the user to use a HoloLens visor to see the impact their probe manipulation has on the cardiac ultrasound imaging and better shows the orientation of the ultrasound probe, the 2-D ultrasound image slice and the relation to the anatomy. It was displayed at the 2019 Radiological Society Of North America (RSNA) meeting.

Modus QA is proud to offer a superior phantom for quantifying geometric distortion in modern MRgRT applications. Watch this video to discover how the entire QA process including set-up and data analysis can be completed in under 10 minutes.

David Sjostrom, Ph.D., deputy chief physicist, Herlev Hospital, Department of Oncology, Division of Radiotherapy, Herlev, Denmark, shares the first clinical experience treating cancer patients with the Varian Ethos radiation therapy system. He spoke to ITN at ASTRO 2019, where he presented information on the first 5 patients in the world being treated with this new technology. It uses artificial intelligence to take the onboard cone beam CT scans to automatically create an adaptive plan for any changes in patient weight loss, bladder volume, or change in tumor size. The plan can be available in minutes while the patient is on the table. It enables sparing of more healthy tissue and makes adaptive therapy much easier to use.